You can enter your credit card details (Number, Exp. Date, Name on the Card) and send it at our fax 732-738-8877.


Credit Card __________________________________ Exp. Date _______________________


Name on the Card ___________________________________________________________

 

To order the Intellewave HRV system please fill out the form below:

First Name: __________________________ Last Name: __________________________
Company: __________________________
Direct Phone: __________________________ Cell: __________________________
Email: __________________________
Your PO#: __________________________ Date: __________________________
Name of distributor: ____________________________________________________
ITEM NO. Enter QTY DESCRIPTION PRICE TOTAL
1 _______ Intellewave HRV System Available upon request ___________
2 _______ Expert Correction Service
per Intellewave Test Unit		 $25.00 ___________
      TOTAL: ___________

Payment By: Visa MC American Express Discover Check Echeck Wire
To provide us with payment instructions, please leave your contact information (phone number and best time to reach you) or send fax at 732-738-8877 or call us at 732-738-8800.
My Contact Info:

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Shipping Address:
First Name: __________________________ Last Name: __________________________
Company: __________________________
Address: __________________________
City: __________________________
State: __________________________ Zip code: __________________________
Country: __________________________
Direct Phone: __________________________ Cell: __________________________
Fax: __________________________
Email: __________________________ Web site: __________________________

Billing Address:

  
First Name: __________________________ Last Name: __________________________
Company: __________________________
Address: __________________________
City: __________________________
State: __________________________ Zip code: __________________________
Country: __________________________
Direct Phone: __________________________ Fax: __________________________

Notes or Special Instructions:

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